UROTHERAPY IN CHILDREN WITH

CEREBRAL PALSY AND INCONTINENCE

Bieke Samijn, PTChristine Van den Broeck, PT PhD

2

Doctoral advisory committee

Prof. Dr. Johan Vande WalleProf. Dr. Frank Plasschaert

Supervisor: prof. Dr. Erik Van LaeckeCo-supervisor: prof. dr. Christine Van den Broeck

Guiding professors

Prof. Dr. Piet HoebekeProf. Dr. Karel Deblaere

INDEX

I. WHAT’S IN A NAME

II. PREVALENCE

III. RISK FACTORS

IV. EVALUATION

V. TREATMENT – UROTHERAPY

VI. UROTHERAPY AS EVIDENCED BASED TRAINING

VII. CASE

WHAT’S IN A NAME…

Lower urinary tract symptoms

= LUTS

NIH

ICCS, 2015

Storage

symptoms

Voiding

symptoms

Other

symptoms

Pain

Increased frequency Hesitancy Holding maneuvres Bladder pain

Decreased frequency Straining Feeling of incomplete

emptying

Urethral pain

Incontinence Weak stream Retention Genital pain

Urgency Intermittency Post micturition

dribble

Nocturia Dysuria Spraying of the

urinary stream

PREVALENCE

• Typically developing children (primary school)

• 5-10 % enuresis

• 2-4 % enuresis + daytime incontinence

Daytime incontinence Enuresis

UNDERLYING CONDITIONS

Typically developing children

OVERACTIVE BLADDER

STORAGE

DYSFUNCTION

DYSFUNCTIONAL VOIDING

VOIDING

DYSFUNCTION

PELVIC FLOOR

OVERACTIVTY

ICCS, 2015

UNDERACTIVE BLADDER

VOIDING

DYSFUNCTION

12

FUNCTIONAL NEUROGENIC

Typicallydeveloping

Cerebral palsy

13

Panicker et al. (2015)

PREVALENCE in children with CP

STORAGE SYMPTOMS VOIDING SYMPTOMS

Symptoms n Pooled Average

Incontinence 1523 46 %

Urgency 508 38.5 %

Frequency 371 22.5 %

Symptoms n Pooled Average

Hesitancy 409 24 %

(R)UTI 797 8.5 %

UUTD 572 2.5 %

STORAGE SYMPTOMS

Symptoms n Pooled Average

Incontinence 1523 46 %

Urgency 508 38.5 %

Frequency 371 22.5 %

Suprapontine lesions

Neurogenic detrusor overactivity

Insufficient fluid intake

Bladder capacity

VOIDING SYMPTOMS

Symptoms n Pooled Average

Hesitancy 409 24 %

(R)UTI 797 8.5 %

UUTD 572 2.5 %

Pelvic floor overactivity

CLINICAL RELEVANCE of CONTINENCE

Quality of life

Financial costs

CHILD

FAMILY

CAREGIVER

RISK FACTORS FOR INCONTINENCE

CASE GROUP: 34 children

CONTROL GROUP: 45 children

27 % 32 % 22 %

27%

27%17%

18%

11%

Functional impairment (GMFCS)

Level I

Level II

Level III

Level IV

Level V

STORAGE AND VOIDING DYSFUNCTIONRisk factors: urgency, maximum voided volume & feeling of

incomplete emptying

CONSTIPATION

ORAL FLUID INTAKE

UROFLOWMETRYRisk factors: Not being able to void or void < 50% of MVV

GET TO THE TOILETRisk factors: functional impairment, need for external aids,

bilateral CP & non-spasticity CP

UNBUTTON PANTSRisk factors: manual impairment & quadriplegia

COMMUNICATE THE NEED TO VOIDRisk factors: communication impairment & intellectual disability

Anamnesis

Bladder diaries

Urinalisys

Ultrasound

Uroflow with post void residual

Invasive urodynamics

…..

EVALUATION

RECORDDATA

BLADDER DIARIES

TREATMENT - UROTHERAPY

STANDARD UROTHERAPY

SPECIFIC INTERVENTIONS

Information, instructions and education

Life-style advice

Registration of symptoms and voiding/drinking habits

Regular follow-up

Pelvic floor muscle training (manually or biofeedback)

Neuromodulation

Behavioral modification

Catheterization

STANDARD UROTERHAPY

• Education

• Toilet posture

• Fluid intake

• Toilet moments

• Voiding frequency

• Capacity training

• Bladder signal trainig (alarm)

Adapted toilet chair

• Individually• School; home; …• Passive/active

• Feet supported

• 90/90 posture

• Legs open

• Back straight

• Full support of thighsOccupationaltherapist

TOILET POSTURE

FLUID INTAKE

Why should we drink?

• Constipation

• Positive experience of

voiding success

• Urinary tract infection

• Kidney problems

• Bladder instability

• Bladder capacity

• Swallowing problems

• Drinking↔ Playing

• Overestimation

• Progress

• Non-oral fluid intake

Speech therapist

CONSIDERATION IN CHILDREN WITH CP

OVERESTIMATION PROGRESS

Monday Tuesday Wednesday Thursday

10:00 50 20 50 100

12:30 90 90 70 90

15:30 90 90 90 20

TOTAL 230 200 210 210 + Child's bib not measured

“If he’s on the toilet for half an hour, he always pees”

TOILET MOMENTS

1) Everytime after eating (4x)

2) Before going to bed

3) Extra in the morning

4) Extra in the afternoon Externalaids

Caregivers

FacilityTime

TOILET MOMENTS/VOIDING FREQUENCY

TREATMENT - UROTHERAPY

STANDARD UROTHERAPY

SPECIFIC INTERVENTIONS

Information, instructions and education

Life-style advice

Registration of symptoms and voiding/drinking habits

Regular follow-up

Pelvic floor muscle training (manually or biofeedback)

Neuromodulation

Behavioral modification

Catheterization

PELVIC FLOOR MUSCLE TRAINING

RELAXATION

Pelvic floor overactivity

• Weigh up the pros and cons of different methods

• Surface electrodes with spasticity

• Visual AND verbal feedback, no audio signals

• Transfer to the toilet EDUCATE AND PRACTISE

CONSIDERATION IN CHILDREN WITH CP

NEUROMODULATION

STANDARD

UROTHERAPY

SPECIFIC UROTHERAPY

orPHARMACOTHERAPY

OTHER

Typical development Urotherapy = effective

Cerebral palsy Urotherapy = effective ?

PHARMACOTHERAPYMICTURITION REEDUCATION

RECRUITMENT

Daytime or combined incontinence

5-12 years old

21 CASESCerebral Palsy

24 CONTROLSTypical development

MEASUREMENTS

UROFLOWMETRY QUESTIONNAIRE BLADDER DIARIES

UROTHERAPY AS EVIDENCED BASED TRAINING

STANDARD

UROTHERAPY

STANDARD UROTHERAPY

SPECIFIC UROTHERAPY INTERVENTIONS

PHARMACOTHERAPY

Evaluation Evaluation Evaluation Evaluation Evaluation

Start 3 Months 6 Months 9 Months 12 Months

TRAINING

Variabele 0 months 6 months 12 months 0-6 months 6-12 months

x (± SD) x (± SD) x (± SD) Mean Difference Mean Difference

MVV (%EBC) 39.0 (± 33,6) 63,5 (± 38,6) 58,2 (± 30,4) 22,4 -10,41

Fluid intake (%RFI) 55,1 (± 15,4) 62,7 (± 19,8) 61,1 (± 14,3) 7,27 -3,66

Frequency EN 5,8 (± 2,6) 5,1 (± 2,8) 3,5 (± 3,2) -0,82 -1,37

Frequency DI 5,6 (± 2,0) 4.0 (± 3,2) 1,8 (± 2,9) -1,21 -2,1

n (%) n (%) n (%) Odds Ratio Odds Ratio

Storage symptoms No 9 (89) 3 (37) 1 (11) 4,8 13,33

Voiding Symptoms No 8 (61) 9 (69) 8 (67) 1,79 0,89

Toilet Posture Correct 11 (52) 13 (93) 9 (75) 10,35 1,06

Adequate fluid intake* Yes 2 (10) 5 (36) 4 (33) 6,07 0,9

Functional constipation Yes 6 (29) 0 (0) 0 (0) - -

FI Continent 4 (19) 8 (38) 10 (48) 2,62 1,48

Smooth curve Yes 2 (10) 4 (29) 7 (64) 3,68 4,38

Bell-shaped curve Yes 2 (10) 4 (29) 6 (55) 3,68 3

UI Continent 0 (0) 0 (0) 3 (14) - -

EN Continent 3 (14) 3 (14) 5 (24) 1 4,75

DI Continent 0 (0) 2 (9) 7 (33) - 4,75

Severity DI Dry 0 (0) 2 (14) 7 (58) 0,32 2,09

Underpants only 5 (24) 3 (21) 0 (0)

Underpants/totally wet 1 (5) 1 (7) 1 (8)

totally wet 15 (71) 8 (57) 4 (33)

RESULTS CEREBRAL PALSY

50 % improvementdaytime incontinence

50 % improvementenuresis

CEREBRAL PALSY VS. TYPICALLY DEVELOPING

Daytime incontinence Enuresis

43

CASE

Iris is a girl of 7 years old with cerebral palsy. She wears diapers during the day and night.

She never sat on a toilet before. Her cerebral palsy is classified as dystonic quadriplegia

with little to no spasticity. She is transported by means of a manually driven wheelchair.

She can stand with support. She can sit independently. Cognitively, Iris is estimated at an

age of 4 years old. She follows school at a rehabilitation centre for children with severe

motor and/or cognitive impairment. The family has two other children. Iris’ mother stays

home to take care of the children. Iris uses medication glycopyrrioniumbromide (anti-

cholinergic) for drooling.

Parents ask if Iris can be continent for stool and urine.

44

FIRST STEP?

EDUCATION

ADAPTED TOILET CHAIR

TOILET MOMENTS

BLADDER DIARIES

NEXT STEP?

EDUCATION – Bladder/stool feeling

DRINKING SCHEDULE

NEED FOR LAXATIVES?

- Fluid intake 1300 ml/dag

- Soft, daily stool, sometimes on toilet

- Iris does not say when she has to void, but correctly tells

mom she does not have to void when put on toilet

- Normal volume of voids (240 ml) and good uroflow

NEXT STEP?

ALARM TREATMENT

START

After 1 month

After 1,5 months

After 4 months

53

TAKE HOME MESSAGES

WORK STEPWISE

FLUID INTAKE

CONSTIPATION

BLADDER CAPACITY

CONTINENCE

ADAPT ENVIRONMENT

WORK INTERDISCIPLINARY

FAMILY

OCCUPATIONAL THERAPIST

REMEDIAL EDUCATIONALIST

SPEECH THERAPIST

PHYSIOTHERAPIST

PARENTS

TEACHERUROLOGIST

PSYCHOLOGIST

NURSE

………………….

THANK YOU FOR YOUR ATTENTION!

Bieke Samijnbieke.samijn@ugent.be

REFERENCES

Austin, P.F., Bauer, S.B., Bower, W. The standardization of terminology of lower urinary tract function in children and adolescents: Update

report from the standardization committee of the International Children's Continence Society. Neurourol Urodyn, 2015.

Samijn, B., Van Laecke, E., Renson, C. Lower urinary tract symptoms and urodynamic findings in children and adults with cerebral palsy: A

systematic review. Neurourology and urodynamics, 2016.

Mulders, M.M., Cobussen-Boekhorst, H., de Gier, R.P. Urotherapy in children: quantitative measurements of daytime urinary incontinence

before and after treatment according to the new definitions of the International Children's Continence Society. J Pediatr Urol, 2011. 7(2): p. 213.

Hjalmas, K. Urodynamics in normal infants and children. Scand J Urol Nephrol Suppl, 1988. 114: p. 20.

Samijn, B., Van den Broeck, C., Deschepper, E. Risk Factors for Daytime or Combined Incontinence in Children with Cerebral Palsy. J Urol, 2017.

198(4): p. 937.